Medicare Plan of Care for Outpatient Therapy: Contents, Certification and the 30- and 90-Day Clocks
A missing certification is a technical denial. That is the phrase the Medicare Benefit Policy Manual uses, and it means a statutory requirement was not met, not that anyone questioned your clinical judgment. The plan of care is the thing being certified, so getting the plan right and getting it signed on time is the single highest-value piece of paperwork in outpatient therapy.
The sources are 42 CFR 410.61, 42 CFR 424.24 and sections 220.1.2 and 220.1.3 of chapter 15 of the manual.
Contents
Who can establish the plan
The plan must exist before treatment starts, and it is established when it is written or dictated. It can be established by a physician or non-physician practitioner, or by the physical therapist, occupational therapist or speech-language pathologist who will provide the services. The signature, professional identity and date of the person who established it are recorded with the plan.
Establishing the plan and certifying it are different acts. A therapist can establish the plan; only a physician or NPP can certify it. Treatment can begin before the plan is committed to writing only if the same clinician who establishes the plan performs or supervises the treatment. Services provided before any plan exists may be denied.
The three things every plan must contain
The regulation sets a short minimum. The plan must contain the diagnoses, the long-term treatment goals, and the type, amount, duration and frequency of therapy services. The manual expands each of those words:
- Type: PT, OT or SLP, or a specific intervention. Each discipline needs its own plan with its own diagnosis and goals; a PT cannot treat under an OT plan.
- Amount: the number of treatment sessions in a day. If it is not stated, one a day is assumed.
- Frequency: the number of sessions in a week. If it is not stated, one a week is assumed.
- Duration: the number of weeks, or the number of sessions, for this plan of care.
Goals that hold up
Long-term goals are developed for the whole episode of care in the current setting, and they should be measurable and pertain to identified functional impairments. Short-term goals are optional under the regulation, but nearly every clinician writes them, and the manual assumes you will use them to track progress within the episode. If the episode is short, four to six treatment days, long-term and short-term goals may be the same.
Where measurable goals genuinely cannot be achieved, because care was transferred or the patient had an exacerbation that ended the episode, say so. The manual asks for the clinical reason progress cannot be shown, not for silence.
Tapered frequency is explicitly allowed and you do not have to project the exact number of sessions at each level. The manual’s own example is “once daily, 3 times a week tapered to once a week over 6 weeks.” Plan the beginning and end frequencies and adjust from daily assessment. Changing frequency within the plan does not require recertification unless the physician asks for it.
Initial certification: the 30-day clock
Certification is a dated signature on the plan of care, or on another document that indicates approval of it. A physician’s progress note, an order, or a signed and dated plan all qualify, as long as the physician is aware treatment is in progress and records no disagreement. The format and the method are up to the practice.
Timing is the part that matters. Certification is timely when it is dated within 30 calendar days of the first day of treatment, and the first day of treatment includes the evaluation. A verbal order to certify counts on the day it is given, provided it is followed within 14 days by a signature. Get the plan to the physician as soon as it is established, and keep evidence that you sent it. A contractor can take that diligence into account if the signature comes back late.
One certification covers the duration of the plan or 90 calendar days from the initial treatment, whichever is shorter. If the whole episode fits inside the initially certified plan, no recertification is needed.
| Day | What is due | Manual reference |
|---|---|---|
| Day 0 | Initial evaluation; plan of care established | Ch.15 §220.1.2 |
| Day 10 | Progress report due, and every 10 treatment days after | Ch.15 §220.3 |
| Day 30 | Certification dated within 30 days of the first day of treatment; a verbal order needs a signature within 14 days | Ch.15 §220.1.3.B |
| Day 90 | Recertification, or earlier on significant change | Ch.15 §220.1.3.C |
Recertification: the 90-day clock
Recertification is due whenever a significant modification of the plan becomes evident, or at least every 90 days after treatment under that plan began. The physician may certify for any duration up to 90 days, and it does not have to be the same physician who certified initially.
What counts as significant? A change in long-term goals, for example a new condition to be treated. That needs physician approval, and certification of the modified plan within 30 days of the first treatment under it. What does not count? A change in frequency or duration because of the patient’s illness, or a change to short-term goals that still serve the same long-term goals. Procedures and modalities are means, not goals, and adjusting them as the patient progresses does not need a signature.
A therapist may delete an intervention from the plan before physician approval when a goal has been achieved or the patient has not responded, as long as the physician responsible is told before the next certification.
Delayed certification saves claims
This rule is the one most worth knowing. A certification is acceptable without any justification for 30 days after it was due. After that, a physician can still certify at any later date, accompanied by a reason for the delay, and the manual says that delayed certification should be accepted unless the contractor has reason to believe no physician was involved in the patient’s care or the treatment did not meet the patient’s needs.
The manual’s own example: a certification signed two years after treatment should still be paid when the record shows a physician approved needed treatment, through an order, a note of a therapist and physician discussing the plan, a request for certification, or certifications for the intervals before and after. It should be denied when the record shows nothing of the kind and the signing physician had no knowledge of the patient.
So a late signature is a problem you can fix. A record with no trace of physician involvement is not, and the treatment notes for the delayed dates still have to meet the four required elements.
Who can and cannot certify
A physician for these purposes is a doctor of medicine, osteopathy, podiatric medicine, or optometry (low vision rehabilitation only). Non-physician practitioners are physician assistants, clinical nurse specialists and nurse practitioners, where state law allows. Chiropractors may not certify or recertify therapy plans of care, and neither may dentists. Podiatrists certify only within their state scope, and optometrists only for low vision services.
When the evaluation is the whole plan
If an evaluation is the only service in the episode, the evaluation itself serves as the plan of care, provided it contains a diagnosis (or, where a therapist may not diagnose, a description the physician can determine a diagnosis from). The physician’s referral or order counts as certification that the evaluation was needed. When there is no order and no treatment follows, a physician referral or certification of the evaluation is still required, and one dated after the evaluation is read as certifying the plan to evaluate.
The plan and the evaluation can be one document or two. Either way, how the progress report refers back to the plan’s numbered goals is what ties the episode together.
Where Carearoo fits
Carearoo drafts the evaluation and plan of care for US therapists so that it always carries the three required contents, states amount, frequency and duration explicitly, and numbers the long-term goals so later progress reports can refer to them. It is live from the US page, on your own template, and your first report is free. Free invoicing is on the same account, in US dollars with your routing and account numbers on the invoice.
Frequently asked questions
How long is a Medicare plan of care certification valid?
For the duration of the plan or 90 calendar days from the first day of treatment (including the evaluation), whichever is less. The physician can certify for less than 90 days if that better matches the expected episode.
Does a change in visit frequency need recertification?
No. A change in frequency or duration because of the patient’s illness is not a significant change. A change in long-term goals is, and that needs physician approval and certification within 30 days of the first treatment under the revised plan.
Is a physician order required for Medicare outpatient therapy?
No. There is no Medicare requirement for an order. Certification of the plan of care is what is required. An order is still prudent because it evidences physician involvement, and a signed order that includes a plan of care needs no further certification.
What if the physician signs the certification late?
A certification is accepted without justification for 30 days after it was due. Later than that, it can still be accepted with a reason for the delay, as long as the record shows a physician was involved in the patient’s care at the time.
Can a nurse practitioner certify a therapy plan of care?
Yes, where state and local law permit. Nurse practitioners, physician assistants and clinical nurse specialists are non-physician practitioners who may certify. Chiropractors may not.
How this guide was written
Carearoo researches and drafts its guides with AI assistance, working from the primary sources linked in the text, and a person checks every fact against those sources before it is published. Last checked 16 September 2026.
Reports for US clinicians are coming. Invoicing is free today.
Carearoo is building Medicare, IDEA and FCE report drafting for US therapists from the federal rules themselves, and nothing goes live until it is tested. In the meantime the invoicing is free: US dollars, routing and account numbers, PDF export, no subscription.